Pediatric Coding Alert

Question: A parent brings her 14-year-old son to the office with an injured right finger he suffered during a skiing accident. He is an established patient. The pediatrician diagnoses a closed metacarpal fracture, which he resets using manipulation and places in a plaster cast. He tells the parent to follow up with an orthopedist for continuing care. Notes indicate a level-two preprocedure E/M service. What modifier should I append to the E/M code?

North Carolina Subscriber

Answer: Many private payers (and Medicare) want you to append modifier 57 (Decision for surgery) to the E/M service code each time the physician provides definitive fracture care and an E/M during the same encounter.

For these payers, report the following:

• 26605 (Closed treatment of metacarpal fracture, single; with manipulation, each bone) for the fracture care
• Modifier 54 (Surgical care only) appended to 26605 to show that you are coding the procedure only and not coding for the follow-up care
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the E/M service
• Modifier 57 appended to 99212 to show that the E/M and fracture care were separate services and that the E/M service resulted in the initial decision to perform the procedure
• 815.00 (Fracture of metacarpal bone[s]; closed; metacarpal bone[s], site unspecified) appended to 26605 and 99212 to represent the patient's injury; and
• E003.2 (Activities involving ice and snow; Snow [alpine][downhill] skiing, snow boarding, sledding, tobogganing and snow tubing) appended to 26605 and 99212 to document the activity that led to the injury.

However: Some payers will prefer that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code when billed in conjunction with certain fracture care codes.

If you're unsure about a private payer's policy on pre-fracture E/M modifiers, check your contract before filing the claim.